What is the treatment for osteopenia?

Treatment of Osteopenia

Treatment decisions for osteopenia should be based on fracture risk assessment using the FRAX tool, with pharmacological therapy reserved for high-risk patients (≥3% 10-year hip fracture risk or ≥20% major osteoporotic fracture risk), while all patients should receive non-pharmacological interventions including calcium, vitamin D, and lifestyle modifications. 1, 2, 3

Risk Stratification Algorithm

Step 1: Calculate FRAX Score

• Use the WHO FRAX tool incorporating BMD and clinical risk factors to determine 10-year fracture probability 1, 3
• Treatment threshold: ≥3% hip fracture risk OR ≥20% major osteoporotic fracture risk 1, 2, 3
• For glucocorticoid users (>7.5 mg/day prednisone), multiply FRAX scores by 1.15 (major osteoporotic) and 1.2 (hip fracture) 1, 3

Step 2: Identify High-Risk Features

• Age ≥65 years with T-score <-2.0 (advanced osteopenia) 4
• Prior fragility fracture (warrants treatment regardless of BMD) 2, 3
• Long-term glucocorticoid therapy >7.5 mg/day 1, 2
• Additional risk factors: low body weight, smoking, family history of fractures, decreased physical activity, alcohol/caffeine use 4

Non-Pharmacological Management (All Patients)

Calcium and Vitamin D Supplementation

• Calcium: 1,000-1,200 mg/day through diet or supplements 1, 2, 3
• Vitamin D: 600-800 IU/day, target serum level ≥20 ng/mL 1, 2, 3
• Caution: Avoid excess calcium dosing due to risk of hypercalcemia and kidney stones 4

Exercise Prescription

• Weight-bearing and resistance training exercises to improve bone density 1, 2, 3
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 3
• Minimum 30 minutes of moderate physical activity daily 3

Lifestyle Modifications

• Smoking cessation (mandatory) 1, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 3
• Maintain healthy body weight (low BMI is independent risk factor) 4, 2, 3

Fall Prevention Strategies

• Vision and hearing checks 3
• Medication review for sedating agents 3
• Home safety assessment 3

Pharmacological Treatment Decision Tree

Treat if ANY of the following:

1. FRAX score meets threshold (≥3% hip or ≥20% major osteoporotic fracture) 1, 2, 3
2. Age ≥65 years with T-score <-2.0 AND additional risk factors 4, 2
3. Prior fragility fracture 2, 3
4. Long-term glucocorticoids >7.5 mg/day 1, 2

Do NOT routinely treat:

• Women <65 years with mild osteopenia (T-score -1.0 to -1.5) 4
• Women ≥65 years with mild osteopenia (T-score -1.0 to -1.5) without additional risk factors 4

First-Line Pharmacological Therapy

Oral Bisphosphonates (Alendronate preferred)

• First-line due to safety, cost, and efficacy 1, 2, 3
• Evidence shows 73% fracture risk reduction in advanced osteopenia (T-score near -2.5) 4
• Administration: Take on empty stomach in morning, 0.5-2 hours before food, separate from calcium supplements 2
• Duration: 1.5-3 years demonstrated in trials 4

Alternative Agents (if oral bisphosphonates not tolerated/appropriate):

• IV bisphosphonates (zoledronic acid) 1, 2, 3
• Denosumab 1, 2, 3
• Teriparatide (for highest-risk patients) 1, 3
• Raloxifene (selective estrogen receptor modulator) 2, 3

Important Caveat on Evidence Quality

The American College of Physicians notes that evidence for treating osteopenia is low quality, derived from post hoc analysis of risedronate trials in women with advanced osteopenia near the osteoporosis threshold 4. However, fracture reduction benefits appear similar across all bisphosphonates based on osteoporosis data 4. The balance of benefits versus harms (including long-term bisphosphonate adverse effects) is most favorable when fracture risk is high 4.

Special Population Considerations

Cancer Survivors

• Baseline osteoporosis risk plus treatment-related bone loss warrants earlier intervention 1, 2
• Bisphosphonates or denosumab are preferred agents 2, 3
• Mandatory: Dental screening exam before initiating bone-modifying agents to reduce osteonecrosis of jaw risk 2, 3

Chronic Liver Disease

• BMD testing indicated for cirrhosis or severe cholestasis 1, 2
• Assess for vitamin D deficiency, thyroid function, hypogonadism 1, 2
• Avoid anabolic steroids (cause abnormal liver biochemistry) 2, 3

Inflammatory Bowel Disease

• 40-50% have osteopenia 2
• Calcium and vitamin D recommended if T-score <-1.5 2

Monitoring Protocol

Repeat DXA Scanning

• Every 2 years to monitor treatment response 1, 2, 3
• Never more frequently than annually 1, 2, 3
• If not treating: repeat in 1-2 years based on risk 2

Clinical Reassessment

• Fracture risk reassessment every 12 months (especially glucocorticoid users) 1, 3
• Medication adherence assessment at each visit 1, 2
• Consider discontinuation if T-scores improve significantly 3

Critical Pitfalls to Avoid

Adherence Issues

• Only 5-62% of patients on glucocorticoids receive appropriate preventive therapies 1, 3
• Non-adherence is extremely common and eliminates treatment effectiveness 1, 2
• Address barriers to adherence proactively 1, 2

Missed Secondary Causes

• Always identify and treat: vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure 1, 3
• These must be addressed regardless of pharmacological treatment decisions 1, 3

FRAX Limitations

• No RCT evidence demonstrates fracture reduction benefit when using FRAX for treatment decisions 4
• FRAX not validated in HIV-infected persons and may underestimate their fracture risk 1
• One raloxifene trial showed treatment efficacy did not vary by FRAX score 4

Bisphosphonate Duration

• Risk of severe adverse effects increases with prolonged use 4
• Reassess need for continuation periodically based on BMD response 3